Surgical Management of Malignant Colonic Obstruction Joint Hospital Surgical Grand Round Surgical Management of Malignant Colonic Obstruction Dennis CK Ng North District Hospital 21-1-2006

Introduction Colorectal cancer is common in HK 3519 new cases in 2002 1965 males, 1554 females M:F = 1.3 to 1 Department of Health, HKSAR 2003

Incidence

Malignant Colonic Obstruction 8-29% of colorectal cancer presented as obstruction Ohman 1982, Philips RK 1985 Serpell JW 1989, Setti Carraro 2001 Most are elderly patient Gerber et al 1962, Anderson 1992

Location 12-19% will have a perforation at presentation Phillips RK 1985 Rovito PF 1990 Sjodahl R 1992 12-19% will have a perforation at presentation Umpleby HC 1984, Runkel NS 1991

Diagnosis

Management Depends on location of tumor Operation remains the main stay of treatment

Right Side Obstruction Right hemicolectomy Primary anastomosis Exteriorisation of both ends Ileotransverse bypass

How to Choose? Emergency right hemicolectomy with primary anastomosis in obstructing tumor Widely accepted approach in most patient Irvin 1977, Fielding 1979 Phillips 1985, Runkel 1991, Carty 1992 Exteriorization of both end in less favourable condition Rarely, bypass only in unresectable locally advanced disease

Emergency Right Hemicolectomy Emergency right hemicolectomy with primary anastomosis in obstructing tumor Mortality 17% Anastomosis leak 10% 6% in elective right hemicolectomy Dudley H 1987 HA COC Surgery 2005 Review on emergency colectomy in 14 HA Hospital Emergency R hemicolectomy leakage rate ~10-15%

Left Side Obstruction Three Stage (1950s, 1960s) Two Stage (1970s, 1980s, 1990s) One Stage (1980s, 1990s)

Three Stage Defunctioning colostomy Resection of tumor Closure of colostomy

Three Stage Disadvantage Advantage Multiple operations Decreased long term survival when compared with primary resection Mortality 20% Advantage Short first operation Frail patient Defunctioning stoma as protection of anastomosis Irvin TT 1977, Carson SN 1977

Two Stage Primary tumor resection + Stoma Closure of stoma

Two Stage Still popular in most centers Mortality 10% Umpleby 1984, Gandrup P 1992 Shorter hospital stay than 3 stage Ambrosetti P 1989 Problems Second operation may be difficult Some will have permanent stoma

One Stage Resection of tumor + Primary anastomosis

One Stage Avoidance of stoma Mortality 10% Anastomotic leak 4% Koruth NM 1985 Murray JJ 1991 Deans GT 1994 Anastomotic leak 4% Konishi F 1988 Longer operation

Two Stage vs One Stage “Meta-analysis” Cochrane Database of Systemic Review Curative Surgery for Obstruction from Primary Left Colorectal Carcinoma: Primary or Staged Resection De Salvo et al 2005 Only 1 RCT in literature – poor quality 1 prospective and 3 retrospective case series

Conclusion Meta-analysis not performed as only one poor quality RCT Not possible to draw conclusion from limited number of studies Need large scale RCT Inconclusive De Salvo et al 2005

Segmental Resection vs Subtotal Colectomy Removing synchronous tumors Reduced metachronous tumors in proximal colon Increased frequency of post-op diarrhoea Carty NJ 1993, Hughes ESR 1985, Golighter JC 1975 On-table irrigation with segmental resection Less disturbance on bowel motion Time consuming Complex procedure Deans GT 1994, Carty NJ 1993, MacKenzie S 1992, Tan SG 1991

SCOTIA 1995 Single stage treatment for malignant left-sided colonic obstruction: a prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation British Journal of Surgery 1995; 82: 1622-7 SCOTIA group 1995

Patients 91 patients from 12 centers 47 subtotal colectomy 44 on-table irrigation & segmental colectomy SCOTIA group 1995

Complications SCOTIA group 1995

Stoma Rate SCOTIA group 1995

Bowel Motion Disturbance SCOTIA group 1995

Bowel Motion Disturbance SCOTIA group 1995

Number of Bowel Opening SCOTIA group 1995

Conclusion No significant difference in operative mortality, hospital stay, anastomosis leakage or wound sepsis Significantly higher permanent stoma rate in subtotal colectomy group Significantly more bowel motions in subtotal colectomy group SCOTIA group 1995

Recommendation Segmental resection following intra-operative irrigation was the preferred treatment for left sided malignant colonic obstruction Subtotal colectomy for patients with perforated caecum or synchronous neoplasm in proximal colon SCOTIA group 1995

Colonic Stenting “Bridge” to surgery Mechanical bowel preparation available Change emergency colectomy to semi-elective operation Better optimization (hydration, electrolytes, nutrition) before operation Laparoscopic colectomy possible

Colonic Stenting Self expanding metallic stent Radiologically or endoscopically placed

Case Series Mainar A et al 1999 Large multi-center series Radiological placement of stents Successful in 93% (66/71) 1 perforation 65 undergo single stage surgery 8.6 days after stents

Stents vs Emergency Surgery Binkert CA et al 1999 Retrospective study 26 patients (13 in stents + elective surgery, 13 emergency surgery) Stent successful rate 92% (12/13) Colostomy: 2 in stent group, 10 in surgery group 28.8% cost saving in stents group

Stents vs Emergency Surgery Martinez-Santos et al 2002 Prospective non-randomized study Radiologically placed stent 72 patients, 43 stent group, 29 control group Stent successful rate 95% (41/43) Primary anastomosis in 84.6% of stent group, 41.4% of surgery group Hospital stay, ICU care and severe complication lower in stents group

Conclusion Enables elective colectomy with primary anastomosis Less stoma rates Shorter hospital stay Less ICU care More cost effective Need RCTs

Summary Right Side Obstruction Left Side Obstruction Right hemicolectomy Three Stage Two Stage One Stage Colonic Stent + Surgery No conclusive evidence which is the bests Depends on patients condition, bowel viability, degree of contamination, experience of surgeon

Thank you

Laser Ablation Kiefhaber P 1986 Mansour EG 1992 Nd-YAG laser 75 patient with obstructing tumor Sussessful in 57 patient 2 patient had perforation Post-operative mortality 3.7% Mansour EG 1992 46 patients, 29 had laser before curative resection 1 laser perforation Postoperative mortality 3.4%